# Impact of time to treatment in first occurrence, non-severe Clostridioides difficile infection for elderly patients: are we waiting too long to treat?

## TL;DR

This study finds that delaying antibiotic treatment for non-severe C. difficile infections in elderly patients increases the risk of disease progression.

## Contribution

The study identifies a 64-hour threshold for treatment initiation that is associated with reduced risk of severe C. difficile infection.

## Key findings

- Delayed treatment (after 64 hours) was linked to a 4.6 times higher risk of disease progression.
- Hospital-acquired infections and toxin positivity were more common in patients who progressed to severe disease.
- The association between delayed treatment and progression remained significant across different statistical models.

## Abstract

Data evaluating timeliness of antibiotic therapy in Clostridioides difficile infections (CDI) are not well established. The study’s purpose was to evaluate the impact of time-to-CDI treatment on disease progression.

A case–control study was performed among hospitalized patients with CDI from 1/2018 to 2/2022. Inclusion criteria were age ≥65 years, first occurrence, non-severe CDI at symptom onset, and CDI treatment for ≥72 hours. Cases included patients who progressed to severe or fulminant CDI; controls were patients without CDI progression. Time to CDI treatment was evaluated in three ways: a classification and regression tree (CART)-defined threshold, time as a continuous variable, and time as a categorical variable.

272 patients were included; 136 with CDI progression, 136 patients without. The median (IQR) age was 74 (69–81) years, 167 (61%) were women, and 108 (40%) were immunosuppressed. CDI progression patients more commonly were toxin positive (66 [49%] vs 52 [38%], P = .087) with hospital-acquired disease (57 [42%] vs 29 [21%], P < 0.001). A CART-derived breakpoint for optimal time-to-CDI treatment of 64 hours established early (184, 68%) and delayed treatment (88, 32%). When accounting for confounding variables, delayed CDI treatment was associated with disease progression (adjOR, 4.6; 95%CI, 2.6–8.2); this was observed regardless of how time-to-CDI-active therapy was evaluated (continuous adjOR, 1.02; categorical adjOR, 2.11).

Delayed CDI treatment was associated with disease progression and could represent an important antimicrobial stewardship measure with future evaluation.